Recommendations for Addressing In-Hospital Substance Use From a National Delphi Consensus Process

When people who use drugs are hospitalized, they may use nonprescribed substances, including opioids, stimulants, and cannabis. Most hospitals do not have standardized approaches to address such in-hospital substance use, which may lead to harm and bias.

To develop best-practice recommendations to address in-hospital substance use.

This survey study using 3 rounds of a Delphi process included clinicians and people with lived or living experience (LLE) of substance use disorders. Eligible clinician experts were physicians, advanced practice clinicians, nurses, and social workers who had worked on a hospital-based addiction consultation team for at least 4 weeks in the past year. Eligible experts with LLE self-identified as meeting diagnostic criteria for substance use disorder and experiencing a hospitalization in the prior 10 years. Participants were recruited by email through author contacts and snowball sampling and completed online surveys from February 27 to June 25, 2024.

The main outcome was development of consensus recommendations to address in-hospital substance use. Using a Delphi process, addiction experts identified best-practice recommendations through 3 rounds of surveys. The final survey included 8 categories of recommendations: at the time of hospital admission, once in-hospital substance use is suspected, management of substances and substance use supplies if found, personnel involved in the response, clinical management, documentation, expected outcomes of the response, and systems-level approaches. A content analysis of the free-text comments associated with recommendations meeting consensus for "sometimes implement" or "rarely implement" was performed to better understand when these recommendations should be implemented.

Of 87 experts contacted, 38 participated (response rate, 44%), including 21 clinicians without LLE of SUD (55%), 10 nonclinicians with LLE (26%), and 7 clinicians with LLE (18%). Mean (SD) participant age was 40.3 (10.0) years, and 24 (63%) were cisgender female. Experts identified 84 consensus recommendations, including 49 (58%) that should always be implemented, 4 (5%) that should never be implemented, and 31 (37%) that should be considered depending on the patient and circumstances. Five key concepts were identified in the content analysis of comments related to recommendations with group consensus to sometimes implement or rarely implement: patient autonomy, evidence-based care, feasibility, impact, and harms and unintended consequences.

In this survey study, an expert panel identified best-practice recommendations to address in-hospital substance use, including recommendations to implement and avoid. These recommendations can inform local responses, including hospital policies, to standardize responses to in-hospital substance use in a patient-centered and evidence-based way.